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f <br /> RECEIVED <br /> O C T 10 2018 <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors performingperiodic testing of USTsecondary containment FQW MF–NTAL HEALTH <br /> appropriate pages of this form to report results for all components tested, The completed form, written test proc T <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Valero#3641 Date of Testing:08/10/18 <br /> Facility Address: 1210 E.Hammer Ln.,Stockton CA 95210 <br /> Facility Contact: I Phone (209)-477-3111 ❑Initial ®Repair Test <br /> Date Local Agency Was Notified of Testing: 08/08/18 ❑6 Month ❑Other <br /> Name of Local Agency Inspector(fpresent during testing): Elena Manzo ❑Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Able Maintenance Inc <br /> Technician Conducting Test: Sam Sousa/I.C.0#5254516-UT <br /> Credentials: Q CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester ®ICC UST Service Technician <br /> License Type: License Number: 312844 <br /> 777,7 —77'. <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainin Expires <br /> Available Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 112 <br /> UDC 516 ® ❑ ❑ <br /> 1:1 El El <br /> ❑ ❑ ❑ ❑ 11 El <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> 0— ❑ El 0 11 <br /> ❑ ❑ ❑ ❑ 10 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Used 10 gallon drum left on site. <br /> For any equipment capable of generating a print out of test results,you must attach a copy <br /> of the test report to this certification ❑ System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 08/10/18 <br />